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r <br /> FOR OFFICE USE: `� 1 <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> ------------------------------------------------ <br /> i (Complete in Triplicate) ____------ -- _ <br /> { <br /> i Date Issued IQ'=�9 <br /> E --------------------------------------------------------- This Permit Expires 1 Year From ate Issued <br /> i <br /> F Application is hereby made_to the Sanoaquin rocar Health District for a permit to construct and install the Work h ei <br /> described. This application is made in compliance with County Ordinance No. 549 and exist'in �ules 91idjAe u to <br /> f� <br /> ". S RACT --------- -------�. _ <br /> JOB ADDRESS/LOCAT ON ---- --_Sl- _ '_,_6�- _ f2 �_ ___ 1?_-------- t--_G� <br /> Owner's Name ---- �� �� � - Phone ------------------------------------ <br /> f ---------------------- ei7, <br /> Pho <br /> Address Cit <br /> !s/ ----------. y ---- ----- ---- <br /> Contractor's Name l / -----------------------------------------License #� qg- Phonef�-0~-------•-------- <br /> Installation will serve: Residencey Apartment House❑ Commercial :❑Trailer Court <br /> Motel ❑Other ---------------------------------------••--- ` <br /> Number of living units:.-- ----- Number of bedrooms J7-_--_Garbage Grinder / _ <br /> - --�-- Lot Size - ------ ---� ---'--------------------- <br /> Water Supply: Public System and name ---------------------- ----------------------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay X Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan Adobe [] Fill Material ------------ If yes,type -____-_------___________ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> s <br /> 14EW INSTALLATION: (No septics tank or seepage pit permitted if public sewer isavailable within 200 feet,) 1 <br /> 4r e t' <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size--- _ _ -- -_--_- Liquid Depth T--- .6 <br /> �'� q P <br /> Capacity �^4-0t _ Type��'94=,�_ Material ---- No. Compartments __ ........ <br /> Distance to nearest: Well ---,��__--________________Foundation ----------- Prop. Line -.��..__....._. <br /> LEACHING LINE . No. of Lines -----A------------- Length of each f line/z9p- �-------- Total Length. _049--.--.--_ <br /> D' Boxes_ Type Filter Material tf-/t'� Depth Filter Material _ --------------------------- <br /> Distance to nearest: Well _-- , �--_-__ Foundation _2° -.0.:--------- Property Line --_�,�_ <br />' SEEPAGE PIT Depth --4—�----_- Diameter ----- Number _-__-- <br /> ;Z---------------_ Rock Filled Yes No <br /> Water Table Depth ----_-- --------------------------------Rock Size ---af�_ i-� <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev.-Sanitation Permit# -------------------------------------------- Date --------------.--.---_---_-_-__-_-j <br /> SepticTank (Specify Requirements) --------------------------------------------------- ------ --------------------------------------------------------------------------------- <br /> Disposal <br /> --------------------------------- --------------------------------------------- <br /> Disposal Field (Specify Require ments) ----------------------------------------- ------------------------------------------------------------------------------------------- <br /> -----= -- -------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------- - '-------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prep red this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's C mpensati.on laws of California." <br /> Signed --------- --- ------------6onper) �� <br /> -------------------------------------- Owner <br /> r - - - ---- ------ Title --- <br /> i <br /> f other tha <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- ------ ------------------------------------------------------------- DATE -------------- <br /> BUILDING PERMIT ISSUED -----------!-------------------------------- -------DATE ------------------------ <br /> ADDITIONALCOMMENTS ------------- -----------------------------------------------------------------------------------------------------------------------------•------ ---------- <br /> ------------------------- ------------- ----------------------------------------------------------------------------------------------------------------------------------------- -------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------ <br /> = ------------------------- <br /> Final Inspection by: ---- Date l <br /> s SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b$ Rev. 5M. t ` <br />